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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT IN PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Dul c inea C. 916-373-1166 <br /> A Facility Name CRLLC #2705446 <br /> C Y Phone# 925-884-0800 <br /> I <br /> L Address 1403 Country Club Blvd. <br /> I Cross Street <br /> T <br /> Y Owner/Operator Pacific Convenience and Fuels, LLC Phone#209-957-2900 <br /> C Contractor Name Walton Engineering, Inc Phone# 916-373-1166 <br /> 0 <br /> N Contractor Address P.O. Box 10 2 5 <br /> T CA Lic# 617238 Class A,B Haz <br /> A Insurer State Fund Work Comp# QWC4000674 <br /> 0ICC Technician's Name <br /> T Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T 87 piping sump 10 K 87- Gasoline <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Nam Date C fir- l r 1, <br /> APPLICANT MUST PERFORM ALL 0RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicants Signat Title Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Dul c inea COyan TITLECompl i ance Manager PHONE# 916-373-1166 <br /> ADDRESS P.O. Box 10225, West Sacramento, CA 95691 <br /> SIGNATURE DATE � <br /> EH230038(revised 02/20/09) <br /> 1 <br />